Healthcare Provider Details

I. General information

NPI: 1003519273
Provider Name (Legal Business Name): MIRAKELL L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 SILVERTON DR
BATON ROUGE LA
70815-5363
US

IV. Provider business mailing address

1445 SILVERTON DR
BATON ROUGE LA
70815-5363
US

V. Phone/Fax

Practice location:
  • Phone: 225-475-0009
  • Fax:
Mailing address:
  • Phone: 225-475-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MIKIEL THOMAS
Title or Position: OWNER
Credential:
Phone: 225-475-0009